How to switch a patient from 0.5mg of Klonopin (clonazepam) to 10mg of Valium (diazepam) and taper off?

Benzodiazepine Cross-Taper and Discontinuation Protocol

Switch the patient from clonazepam 0.5mg to an equivalent dose of diazepam 5mg (not 10mg), then taper the diazepam by 10% of the current dose every 2-4 weeks until discontinuation. 1, 2, 3

Step 1: Establish Equivalency and Initial Switch

• Clonazepam 0.5mg is approximately equivalent to diazepam 5mg, not 10mg. 4 Starting at diazepam 10mg would represent a dose escalation and increase dependence risk.

• Perform the switch using a gradual cross-taper over 1-2 weeks: 1, 2

  • Days 1-3: Clonazepam 0.5mg + Diazepam 2.5mg
  • Days 4-7: Clonazepam 0.25mg + Diazepam 3.75mg
  • Days 8-14: Discontinue clonazepam, continue Diazepam 5mg

• Diazepam is preferred for tapering because it has a longer half-life than clonazepam (20-100 hours vs 18-50 hours), providing smoother withdrawal symptom control. 4

Step 2: Obtain Patient Agreement and Establish Monitoring

• Secure written informed consent that includes: 5

  • Statement of collaboration and shared decision-making
  • Commitment to treatment adherence and communication about difficulties
  • Clinician commitment to patient non-abandonment
  • Plan for managing withdrawal symptoms

• Screen for anxiety, depression, substance use disorders, and seizure history before initiating taper. 5, 1 Patients with seizure history require even slower tapering. 1

• Schedule follow-up visits at least monthly (ideally every 2-4 weeks initially) throughout the taper. 5, 1, 2

Step 3: Implement the Diazepam Taper

For patients on benzodiazepines long-term (≥1 year), use 10% reductions of the most recent dose every 2-4 weeks: 5, 1, 2

• Week 0-2: Diazepam 5mg daily

• Week 2-4: Diazepam 4.5mg daily (10% reduction)

• Week 4-6: Diazepam 4mg daily

• Week 6-8: Diazepam 3.6mg daily

• Week 8-10: Diazepam 3.25mg daily

• Continue 10% reductions every 2-4 weeks until discontinuation

• Each new dose should be 10% less than the previous dose, not 10% of the original starting dose. 1, 2 This creates a gradually slowing taper that accommodates increasing physiologic sensitivity at lower doses.

• The entire taper may take 4-6 months or longer depending on patient tolerance. 5, 1

Step 4: Monitor and Manage Withdrawal Symptoms

Common benzodiazepine withdrawal symptoms include: 5, 2

• Physical: tremor, diaphoresis, insomnia, myoclonus, diffuse pain, hypertension, cramping, pupillary dilation
• Affective: dysphoria, anhedonia, anxiety, depression

If withdrawal symptoms occur: 5, 1, 2

• Return to the previous well-tolerated dose and maintain for 2-4 additional weeks 1, 2
• Then attempt a smaller reduction (5% instead of 10%) 1, 2
• Extend the interval between reductions to 4-6 weeks 1, 2

Consider adjunctive medications for specific withdrawal symptoms: 1, 2

• Alpha-2 agonists (clonidine 0.1-0.2mg or tizanidine 2-4mg) for autonomic symptoms like hypertension, tachycardia, diaphoresis 1, 2
• Trazodone 25-50mg for insomnia 6

Step 5: Incorporate Non-Pharmacological Support

Implement concurrent behavioral interventions: 1, 2

• Cognitive behavioral therapy for anxiety management 1, 2
• Regular exercise and physical activity 1, 2
• Stress management techniques 1, 2

Critical Pitfalls to Avoid

• Never discontinue benzodiazepines abruptly except in cases of confirmed diversion or life-threatening toxicity. 5, 2 Abrupt discontinuation can precipitate seizures in susceptible patients. 1

• Never abandon the patient if they struggle with the taper. 5, 1, 2 Consider pausing the taper rather than discontinuing care. 5, 1, 2

• Do not set arbitrary time limits for completing the taper. 5, 2 The goal is successful discontinuation with minimal distress, not speed. 5

• Avoid tapering faster than 10% every 2-4 weeks for long-term users. 5, 1, 2 Faster tapers significantly increase withdrawal symptoms and failure rates.

• If the patient is also taking opioids, taper the benzodiazepine first due to the dangerous synergistic respiratory depression risk. 1

Special Considerations

• Patients may require very slow tapers (10% per month or slower) if they have been on benzodiazepines for years. 5, 1

• Tapers may need to be paused and restarted when the patient is ready, particularly during life stressors. 5

• As patients reach lower doses (below 2mg diazepam), the taper may need to slow further as physiologic sensitivity increases. 5

• Educate patients about increased overdose risk if they return to previous doses after successful taper, as tolerance will have decreased. 1